I need a safe place to talk!  
Confidential student survey for student concerns
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Email *
Student Name
What is your gender *
When do you graduate? *
Student email address that is used consistently *
What is your phone number?
Are you experiencing any of the following?   *
Required
Do you think you need counseling? *
Would you be willing to participate in a group at school that will help you address the issue that you are confronted with? *
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